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32C-276 • BP- 2011 -0333 GIS #: COMMONWEALTH OF MASSACHUSETTS : C'• 4 _ CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2011 -0333 Project # JS- 2011- 000548 Est. Cost: $2228.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE JUBB CO INC 055333 Lot Size(sq. ft.): Owner: KHERDIAN DAVID Zoning: Applicant: THE JUBB CO INC AT: 82 WILLIAMS ST Applicant Address: Phone: Insurance: P O Box 429 (413) 772 -6217 Workers Compensation GREENFIELDMA01302 ISSUED ON:10/13/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/13/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner Department use only Y City of Northampton status of Permit .� 0 '1, *' Building Department Curb Cut/Drtveway,Permit 212 Main Street Sewer /septic Availabrlrty 4 ' ° ?DTI Room 100 Water/Well Availability OC1 " 8 Northampton, MA 01060 Two Sets of Structural Plans phone Fax 413 -587 -1272 PIotSite Other Spedfy APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 0 � lam , ` (, c' 3 Map Lot Unit n r --1.- rn ( D Or 1 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: „ K 1� er G n 2 LtJ , I I q .S 5-1- Name (Print) Current Mailing Address:. a _ goy ' ( -, f Telephone o �{ Signature 2.2 Authorized Anent: _.. t &6 E 0/4-- Name Print ( ) Current Mailing Address: s: —� —702 - (I Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) er r Check Number /07 7 6 ctY 36 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacemerg,dows Alteration(s) ❑ Roofing ED Or Doors Accessory Bldg. ❑ Demolition ❑ • Other [11=8 Brief Description of Proposed j Work: : P l/ t / —*1 f) dC►—<._ Alteration of existing bedroom No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes . No Plans Attached Roll - Sheet 6a if New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, ( A ){€RC e , as Owner /Authorized Agent her by declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains ap err les of perjury. 4- JJ3V Prird Name Signature of Owner /Agent Date `/ SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ g Name of License Holder : hCA LA ) l e t C e t� 5 5333 License Number fro-f- ,5101 Address Expiration Date A Signature Telephone -Co 9. Renlstered Home Improvement Contractor. Not Applicable ❑ h Co P c s Od - Company Name / Regi . - lion Number Address Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L c. 152, § 25C(8)) Workers Compensation Insurance affid it must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of e buil ing permit Signed Affidavit Attached Yes 1 No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780. Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who on a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • • - :. - .. AFFIDAVIT . • • • . . • • . • As a result of the provisions of MGL c 40, S54, I acknowledge that as a condition of Building Permit • • . Number all debris resulting from the construction activity governed by this • • Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as dettned by MGL . cl11,S 150A_ , . • ; . I certify that I will notify the Building Official by ' . (Two months maximum) of the location of the solid waste disposal facility where resulting from • , the said construction activity shall be disposed of, and I shall submit the. appropriate forn attachment • • to the Building Permit_ • . • • D t Signature of Permit Applicant • • (Print or type the following information) . y '' • ,• • • L. L( . - Name of Permit Applicant • pc). • I - ,... ._ . • " • ; • Firm Name, if any • • . • • • • . • • Address • . ''' • Tfrs' `debris "i fill:.be::' .is "osed''of•:.... • ... .. • .. ... ... .. ";";:'•••'''''..":•* . • ' Ary\ p • • . Loca of Facility) • • • • • • Massachusetts - Ucpartntcnl or P sarel 13n :u'll of Building Ite2ttlaliun, and Stanllarrl, construction tiup.'rvI ; r I rc:cnse License: CS 55333 Restricted to: 00 ` l7 LAWRENCE A JUBB JR �'� te, p PO BOX 429 GREENFIELD, MA 01302 Y Expiration: 5/21/2012 ( uuaui..jImc•r TO: 24599 • • gge ecz.,:weaztx�,2� .,,dtatiee6 Office of Consumer Affairs and usi ness Regulation �( 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 100001 Type: Private Corporation - - - - Expiration: 6/8/2012 Tr# 297762 The Jubb Company, Inc. = =- _ Larry Jubb „ ___.- P. 0. Box 429 Greenfield, MA 01302 , l� \ :>/ . Update Address and return card. Mark reason for change. LI Address 0 Renewal LI Employment 0 Lost Card DPS -CA1 0 50M- 04/04. 0101218 • • d The Commonfveulth of Massachusetts Department of Industrial Accidents 11! _ ?i.,= ( Office of Investigations -tt� - ' 600 Washington Street Boston, MA 02111 • ''a im “a WWW. mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print Legibly — Name ( Business /Organization/Individual): 11 ft . J u k I ) 011 1 C'r1 ►'� C Address: - P. 0. g0 City /State /Zip: �T� �, � �� H Phone #: c / .7 • Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ 1 am a employer with 4. 0 1 am a general contractor and 1 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 0 Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9 ❑ Building addition [No workers' comp. insurance 5. ❑ We arc a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. � - ----�� Insurance Company Name: 'c C. ' j ._t —t lei /�C� ► Policy # or Self -ins. Lic. #: C ' { Expiration Date: 5 3/) Job Site Address: City /State /Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. • I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: -_ _4 _ Date: Phone #: 7 - - (v a--4 7 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 7 L 05/07/2010 15:52 413863 658 AHRIST PAGE 01/01 • ACORD' DATE. :MLVr,D;YYYY•, CERTIFICATE OF LIABILITY INSURANCE 05/07/2010 PRODUCER Monet. o' 413 8G3.4373 Fax, 413.8.33.BG5B TI-03 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION A.H. RIST INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 159 AVENUE A HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. BOX 391 ALT ER THE COVE RAGE AFFORDED "MOW, - TURNERS FALLS MA 01376 INSURERS AFFORDING COVERAGE NAIC !! INSURED INSURER A: PEERLESS INSURANCE COMPANY THE JUBB COMPANY, INC. INSURER B: P.O. BOX 429 INSURER C: GREENFIELD MA 01302 — --- -- INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 'OR THE POLICY PERIOD INDICATED, NCTMITI ISTANDAG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT /JITI•l RESPECT TO W'-IICI I THIS CER1'4'ICATE M W BF I+ SLED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUDJECT TO ALL THE TERMS, FY.CI.USICNS AND CONDITIONS OP SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS MR An01 _ TYPE OP INSURANCE POLICY NUMBER FOLICY EFFECTIVE POLICY EXPIRATIO LIMITS eft: 'N3F• VC'MWv l al DATEMIMMb'YY1 GENERAL LIABILITY CBP 8661749 05/03/10 05/03/11 EACHOCCURRENI:E S _ 1,000.000 © COMMERCIAL. GENERAL LIABILITY SAMAOE TO REIJTED 1 100,000 PREMISQllCn ocoun.n:n) a n CLAIMS MADE n OCCUR MED. F,XP (Any ono DOre^n1 S 15,000 A MI PERSONAL F, ADV INJURY i 1,000.000 GENERAL AGGREGATE .'r. 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPJOP ACC S 2,000.000 POLICY I I PRO- IEGT l .l LOC ... — — .� AUTOMOBILE UABILITY CA 8669247 05/03/10 05/03/11 COMBINED SINOLE LIMI r ANY AUTO (ER RCCJOef;) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Pot pernon) A X HIRED AUTOS BODILY INJURY t X NON-OWNED ALITOS (Par occldanl) PROPERTY DAMAGE (PRr SCOOOnlH S • GARAGE LIAIIIUTY N/A AUTO ONI.Y - hA ACCIDENT - ANY AUTO OTI.IER THAN EA ACC 3 AUTO ONLY: AGO .p EXCESS / UMBRELLA LIABILITY N/A FACI.1 OCCURRENCE $ III OCCUR n CLAIMS MADE AGGREGATE, & . S DF.DUCYIHI.E .� I RETENTION $ 3 WORKERS COMPENSATION AND WC 8664947 05103/10 05/03/11 TOR1 IJM a ' C T r ra EMPLOYERS' LIABILITY YIN / E,L. EACH ACCIDENT $ 100,000 A ANY PeOPRIETOR /•ARTIURRIEXr(cuTIVE ❑ OFFICER/MEMBER EXCLUDED? C L. DISEASE -4A EMPLOYEE 5 500,000 (MIn nfy In NISI Iwyo4, aasanoc under E,I., DISIASE POLICY LIMIT 5 100 000 aDECL1L PP.OVI31ONa below I w... AMP - OTHER N/A DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS CLASSIFICATION: CARPENTRY /SIDING INSTALLATION i WORKERS COMP POLICY INCLUDES COVERAGE FOR CORPORATE OFFICERS CERTIFICATE HOLDER CANCELLATION ' THE JUBB COMPANY, INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIE.4 F.I: CANCELLED 3,.FORF TiII• EXPIRATION DATE THEREOF, THC ISSUING INSURER WILL CNDC,WOR TS) MAIL 10 DAYS P.Q. BOX 429 WRITTEN NOTICE TO T'HH CERTIFICATE HOLDER NA,MCD TO TIME. 1.141, BLIP "ALJRE TO GREENFIELD MA 01302 1)0 SO SSFIALI. IMPOSE NO CHLIGATION DR LIABILITY DIr ANY KING UPON T1 INSURER, ITS AGENTS OR REPRESENTATIVES. AUI HORizED REPRESENTATIVE Attention: r�'�Cp��I.'T,kl ACORD 25 (2009/01) Certificate !f 22985 01988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD We Hrby submit specifications and estimates for: J r . °/nad/HL Of f i W /ivrn c 42rrurlv ti/N io orn /Sze.,iv N5 /4,eve (A )00n /4/ 4/7"efotz (1 J/“.t 41/412_696 (',/ EXr rn / £5CtS77thr- c feet ///VS - /.'Y ,€e Dowd /e �/c•.vo C' 11 Cr t l cts n ,' C 7 1e1d - a St 1z F,rt/S - /a�, j c n� C-71-_, 1. / /eGe L k 4 A r e 2 N PIA ss 1 0,9-Nes - & `E " r- is S sB & c -- M eel- i eo/e, 6 I Nee A! h ✓P ° ket. cxa( le ( r�c'J -S - � l( r L/�D �XT�J2 /d2 (A )COO 7el/i' W t TN (,J IN c j- /i-C .G{M 1 Nit nvi col [, S7 r/c (//ve 1- .4 2 SAC T /aN ABOVE ( - Strt efsiNo - been, -) 175 A .01.12 A lE,V1 7 c--oaer o LP —A GC i //G ON ,,4-j C`S - 4'/r oi/eVact f 14 /!T/( ',)/ S'& bi-/74AJ - C f/veoui Ac,,/ Pep //i = y' A /le S-1-72-( P F i'vn oP CJ r /f dQ�,,o re: ke Meg- ;a NEbt/ / — 2 G4a4- pv /r✓G . Reva ro'I I ci Check 23 g i h , r sk 7 l 3 (AND y21e 14-p to n (Ku ST , e / e,' O 0 067t2Ne i ee - (A—Ayr 6 z! F »R- CA)orte mew Al /3 flap_ GJivpv bird2 cS cWNers fiP.s 264/s /e /Ci FEE: (Includes permit & disposal of all job related refuse) /451f/1/7: SERVICE l0� ( p p � Service fee is not included in amount below and will be billed separately. • Contract Service Charge: An interest charge of 2% per month (24% per annum) will be added to outstanding balances over 30 days, plus all costs, including reasonable attorney's fees, incurred in collecting any sums owed. e ropoge hereby to furnish material and labor - complete in accordance with above specifications, for the sum of: f - ,00 A Z`3 edr) v,� � tp�7 44°A F 0 4 — dollars ($ a ag ). ment t be made Ms ollov �/ } � 3 D oweu uppAr i4c : e ► r� Make check payable to: The Jubb Co., Inc. Final balance is due upon completion. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary Insurance. Our Note: This pro? sal be THIRTY workers are fully covered by Workmen's Compensation Insurance. withdrawn by if not accepted within days. S, t � 't � tance of ro ogat - The above prices, specifications and 4 / conditions are satisfactory and are hereby accepted. You are authorized to do Signature the work as specified. Payments will be made as outlined above. G(D Signature Date of Acceptance: w f/ L White - Jubb Co. Copy Yellow - Customer Copy